Tell Us About Your Child. Who is Accompanying Your Child Today? Parent Information. Primary Dental Insurance

Transcription

1 1 Today s Date: 2 (225) (225) (fax) 245 VETERANS BLVD. DENHAM SPRINGS, LA Who is Accompanying Your Child Today? Name: Relation: Do you have legal custody of this child? Yes No Tell Us About Your Child Child s Name: First Middle Last Nickname: M F Birthdate: / / Billing Address: City: St: Zip: Age: SSN: School: Grade: Address: Whom may we thank for referring you? List other family members seen by us 3 Parent Information Mother Stepmother Guardian Name: Birthdate: / / Cell #: ( ) - Home #: ( ) - Work #: ( ) - Employer: SSN: Father Stepfather Guardian Name: Birthdate: / / Cell #: ( ) - Home #: ( ) - Work #: ( ) - Employer: SSN: Parent s Marital Status: single married partnered separated divorced widowed If foster parent, provide case worker: Name: Ph #: ( ) - 4 Primary Dental Insurance Insurance Co. Name: Insurance Co. Ph. #: ( ) - Group #: Policy Owner s Name: Relationship to Patient: Policy Owner s Birthdate: / / I.D. # Policy Owner s Employer: *If child does not have dental insurance, how do you intend to pay? Cash Check MC / VISA / Discover

2 (225) (225) (fax) 245 Veterans Blvd. Denham Springs, LA Child s Name Birthday / / Medical History Child s Physician Address Phone # ( ) Date of Last Visit Reason Is your child in good physical health? Yes No Is your child up to date with immunizations? Yes No Has your child been hospitalized since birth? Yes No Please check any of the following that may pertain to your child Heart Murmur Epilepsy Latex Allergy Seizures Brain Injury Heart Condition Diabetes Cancer Learning Disability Other ADD/ADHD Lung Problem Cerebral Palsy Tuberculosis Handicaps Autism Bleeding Problem Sickle Cell Anemia Asthma Hearing Problems Anxiety Liver Problem Hepatitis Allergies Sight Problems Other Kidney Problem Aids /HIV+ Sinus Problems Blood Transfusions Please describe any Medical medical condition Condition that was checked above: or any condition that was not listed: Please list all medications your child is taking Is your child allergic to any Medications? medications, food, etc.? Yes o Yes No o No If yes, If yes, list list Dental History Reason Your Child Is Here Today Is this your child s first dental visit? Date of Last Visit Were X-Rays taken? Has your child had an unfavorable experience in a dental office? If yes, please explain Child s Previous Dentist Address Phone # ( ) What is your water source? Private Well Public System Does your child suck their thumb or finger? Yes No Does your child use a pacifier? Yes No Was your child bottle fed? Yes No Age it was discontinued Has your child ever had trauma to their teeth? Yes No Do you assist your child with tooth brushing? Yes No Sometimes Permission I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsiblitity to inform this office of any changes in my child s medical status. Parent/Guardian s Signature Date

3 Consent for Dental Treatment State Law requires us to obtain your consent for dental treatment. Please feel free to ask any questions you may have. In general terms, contemplated treatment is: dental restorations, sealants, extractions, exam, cleaning, local anesthetic, and nitrous oxide. Alternatives to the Recommended Dental Treatment Any alternatives to the recommended treatment, including no treatment, have been explained to me, as have the advantages and disadvantages of each. Risks associated with the Recommended Dental Treatment I understand dentistry is not an exact science and complications may occur despite our best efforts. A partial listing of the risks known to be associated with dental treatment and anesthetic care are: Infections, Bleeding, Failure of wound to heal, Injuries to adjacent teeth or soft tissues, Paresthesia or numbness of tongue, mouth or face, Fracture of Lower jaw or Upper Jaw, opening between mouth and sinus or mouth and nose, Incomplete removal of tooth, Dry socket, Loss of teeth, Loss of bone, Loss of hard or soft tissues, Instrument breakage, Breakage of roots and retained root fragments, Swallowing or aspiration of objects, Allergic reactions to drugs, Jaw Pain or difficulty opening mouth, Bacterial Endocarditis, Additional Oral Surgery, Hospitalization, or further treatment upon complications. State law also requires the we specifically advise you that, although rarely occurring, dental treatment or anesthetic may result in: Death, Brain Damage, Paraplegia, Quadriplegia, Loss of Organs, Loss of Function of an Organ, Loss of function of Face, Arms, Legs, and Disfiguring Scars. Acknowledgment I have read and understand the information stated above. I have been given ample opportunity to ask any questions I may have about treatment. All questions have been answered in a satisfactory manner. I understand the success of this treatment and the avoidance of treatment complications depends upon my complying with the instructions, restrictions, and any recommendations, that have been explained to me. I also understand that I am to notify the dentist immediately of any suspected complications, where further treatment may be discussed or administered, which is not currently anticipated. I, as the patients legal guardian, authorize and request Dr. Joseph A. Yale, Dr. Mary K. McClendon, Dr. Kristoffer Norbo and/or assistants of his choice, to perform any dental procedures, including anesthetic, that deem necessary during treatment. I understand the treatment plan to be presented, along with the fees outlining, could change depending upon the time elapsed since the initial examination and the extent of dental pathology. By signing this I agree to be responsible for full payment of all charges on the above named patient. This consent will remain valid until revoked in writing. All blanks have been filled in prior to my signature. Patient Name Guardian Signature date

4 Louisiana Medicaid We want to help you get the full benefits afforded you by the Medicaid Program. To assist you in receiving these benefits, we will file your Medicaid claims for payment of services we have rendered to you. For your benefit, please let us know of any changes or if your coverage has been terminated. If coverage has terminated and no benefits are paid by Medicaid for services rendered, then the responsibility falls to you to pay in full. Dental Insurance As a courtesy to you, we will assist in filing your dental claims to help you get the full benefit your insurance offers. Please be advised treatment plans are only an estimated cost based on an estimated coverage breakdown given to us by your insurance company. Any cost not covered by insurance is your responsibility. If you have any changes with your insurance company or policy, please inform our office before your next appointment. Attendance Policy The best care for your child is received when you make the appointments we have scheduled together. If for some reason you have to cancel your child s appointment, please call our office 24 hours in advance of your scheduled time. If your child does not show for two scheduled appointments, unfortunately we will no longer be able to reserve future appointments for your family with our office, This rule is important for your child and other children, because we make every effort to plan all appointments to provide the best preventative care. So if you miss yours, most if not all, appointment times are filled and your child misses out on their care. Confirmation Policy Our office REQUIRES that all appointments are CONFIRMED. Several attempts will be made to contact you in regards to appointments. It is your responsibility to ensure that we have spoken to you and received a confirmation that your child will be at his/her appointment. If no confirmation has been received by the working day prior to the appointment, unfortunately this appointment can no longer be held and the appointment WILL BE CANCELLED. I understand and agree to the above terms. Patient s Name: Signed: Date: Parent/Guardian

5 245 Veterans Blvd Denham Springs, La Parent/ Guardian Consent I,, Custodial Parent of, (Minor/ Minors) Authorize Dr. Yale, Dr. McClendon, or Dr. Norbo and their employees to render dental treatment to the above listed child/ children. *If I am unable to attend any appointments with my child(ren), the names listed below are authorized to bring them to their appointments and to discuss my child(ren) s dental care. I also give them permission to make treatment and financial decisions.* Person s Name Relationship to Patient Phone Number Parent/ Guardian Signature: Date:

6 YALE PEDIATRIC DENTISTRY Joseph A. Yale DDS Mary K. McClendon DDS Kristoffer A. Norbo DDS 245 Veterans Blvd. DS, LA (225) (225) (fax) Hipaa OUR NOTICE OF PRIVACY PRACTICES By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post this new notice in our office, have copies available in our office, and post it on our Web site. COMPLAINTS If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone. FOR MORE INFORMATION If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown above. ACKNOWLEDGEMENT OF RECEIPT Patient name Signature Date

7 Photo Release Form We have created a Website, Social Media pages and LED sign for our office. These items provide a fun way to share new things going on in our office and with our patients, as well as update you on important information. Please fill out the bottom of this form granting Yale Pediatric Dentistry permission to post photos of your child on one or all of the places listed above. You may see this picture on or With your signature, you consent as follow: I am legal guardian of and I give Yale Pediatric Dentistry permission for the above patient to be photographed and the pictures to be placed on Social Media,our website, and/or our LED sign. Parent or Guardian Signature Date